Provider Demographics
NPI:1225298011
Name:KUBOYE, KOFOWOROLA MARIAM (MD)
Entity type:Individual
Prefix:
First Name:KOFOWOROLA
Middle Name:MARIAM
Last Name:KUBOYE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 W 1ST ST STE 30
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-8151
Mailing Address - Country:US
Mailing Address - Phone:469-281-2388
Mailing Address - Fax:940-323-0553
Practice Address - Street 1:2810 W 1ST ST STE 30
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-8151
Practice Address - Country:US
Practice Address - Phone:469-281-2388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-15
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS217562080A0000X
390200000X
TXQ6050208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program